Trauma — MCQs
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What is the treatment of choice in pathological fractures?
Which of the following statements about Keinböck's osteonecrosis is FALSE?
In a Guardsman fracture, what type of fractures are present?
Hotchkiss terrible triad does not include which of the following injuries?
What is the management of hemarthrosis?
Which nerve is commonly involved in a fracture of the distal shaft of the humerus?
What is the most important cause of nonunion of a humeral shaft fracture?
What is considered the golden hour for a femur fracture?
All of the following areas are commonly involved sites in pelvic fracture except?
Which tendon is affected in lateral epicondylitis?
Trauma Indian Medical PG Practice Questions and MCQs
Question 401: What is the treatment of choice in pathological fractures?
- A. Internal fixation (Correct Answer)
- B. Plaster of Paris casts
- C. Skin traction
- D. External skeletal fixation
Explanation: **Explanation:** The primary goal in managing a **pathological fracture** (a fracture occurring through diseased bone, most commonly due to osteoporosis, primary bone tumors, or metastatic disease) is to achieve immediate stability, alleviate pain, and allow early mobilization. **Why Internal Fixation is the Correct Choice:** Internal fixation (often combined with bone cement/PMMA) is the treatment of choice because pathological bone has poor healing potential. Unlike traumatic fractures, these fractures rarely unite with conservative management. Rigid internal fixation provides the mechanical stability necessary to allow the patient to ambulate immediately, which is crucial for preventing complications of prolonged recumbency (like DVT or pneumonia), especially in terminal metastatic cases. **Why Other Options are Incorrect:** * **Plaster of Paris (POP) Casts:** These provide inadequate stability for diseased bone. Prolonged immobilization in a cast leads to disuse atrophy and joint stiffness without ensuring union. * **Skin Traction:** This is a temporary measure for pain relief and alignment. It cannot be a definitive treatment as it requires long-term bed rest, which is contraindicated in patients with underlying systemic disease. * **External Skeletal Fixation:** While it provides stability, it carries a high risk of pin-tract infections and loosening in poor-quality bone. It is generally reserved for open fractures or infected non-unions, not routine pathological fractures. **High-Yield Clinical Pearls for NEET-PG:** * **Mirel’s Scoring System:** Used to predict the risk of an impending pathological fracture and decide if prophylactic internal fixation is required (Score $\geq$ 8 indicates surgery). * **Most common cause:** Osteoporosis (overall); Metastasis (in elderly). * **Commonest site of metastasis:** Spine > Femur > Pelvis. * **Role of PMMA:** In lytic lesions, internal fixation is often supplemented with bone cement to fill the void and provide "instant" structural integrity.
Question 402: Which of the following statements about Keinböck's osteonecrosis is FALSE?
- A. Tenderness over the base of the 3rd metacarpal is present.
- B. Pain is more on wrist flexion than wrist extension. (Correct Answer)
- C. It is osteochondritis of the lunate.
- D. The common age group is 20-40 years.
Explanation: **Explanation:** **Kienböck’s disease** is the avascular necrosis (AVN) or osteochondritis of the **lunate bone**. Understanding the anatomy and biomechanics of the carpus is key to identifying the clinical features. **Why Option B is the FALSE statement:** In Kienböck’s disease, **pain is typically more severe during wrist extension** rather than flexion. This is because, during extension, the lunate is compressed between the distal radius and the capitate. This increased axial loading on the necrotic, structurally weakened lunate exacerbates the pain. **Analysis of other options:** * **Option A:** The lunate is located centrally in the proximal carpal row, directly proximal to the **base of the 3rd metacarpal** (via the capitate). Therefore, localized tenderness is most prominent at this anatomical landmark. * **Option C:** It is indeed classified as **osteochondritis** (idiopathic AVN) of the lunate, similar to Perthes' disease in the hip. * **Option D:** The condition typically affects young adults, most commonly in the **20–40 year** age range, often involving the dominant hand of manual laborers. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Strongly associated with **Ulnar Negative Variance** (the ulna is shorter than the radius), which leads to increased force transmission through the lunate. * **Radiology:** The **Stahl Classification** or **Lichtman Classification** is used for staging. Early stages may show normal X-rays (MRI is the investigation of choice), while late stages show sclerosis, collapse, and carpal instability. * **Treatment:** Depends on the stage; options include radial shortening osteotomy (to correct ulnar negative variance) or proximal row carpectomy in advanced cases.
Question 403: In a Guardsman fracture, what type of fractures are present?
- A. Direct fracture of the symphysis with an indirect fracture of the bilateral subcondyle. (Correct Answer)
- B. Indirect fracture of the symphysis with a direct fracture of the bilateral subcondyle.
- C. Direct fracture at both the symphysis and the bilateral subcondyle.
- D. Any of the above combinations.
Explanation: **Explanation:** The **Guardsman fracture** is a classic pattern of mandibular injury typically seen when a person falls forward directly onto the point of the chin (mentum). This is named after Royal Guards who may faint while standing at attention and fall forward without breaking their fall with their hands. 1. **Mechanism of Injury:** The primary impact occurs at the **symphysis or parasymphysis** of the mandible. This represents a **direct fracture** because the bone breaks at the site of impact. 2. **Force Transmission:** The kinetic energy from the impact travels backward through the body and ramus of the mandible to the weakest points—the **condylar necks**. This results in **indirect fractures** of the bilateral subcondylar regions. **Analysis of Options:** * **Option A (Correct):** Accurately describes the mechanism: direct trauma to the chin (symphysis) causing indirect stress fractures at the bilateral subcondyles. * **Option B:** Incorrect because the symphysis receives the direct blow, not an indirect force. * **Option C:** Incorrect because the subcondylar fractures are not caused by direct impact to the condyles themselves, but by transmitted force. * **Option D:** Incorrect as the pattern is specific to the biomechanics of the fall. **NEET-PG High-Yield Pearls:** * **Mandible Fracture Sites:** The most common site of mandible fracture is the **Condyle** (approx. 30%), followed by the Angle and Symphysis. * **Weakest Point:** The condylar neck is considered the "safety valve" of the mandible; it fractures to prevent the condyle from being driven into the middle cranial fossa. * **Clinical Sign:** Patients often present with "deranged occlusion" and restricted mouth opening (trismus). * **Imaging:** The **Orthopantomogram (OPG)** is the gold standard screening view, but a **Reverse Towne’s view** is best for visualizing condylar displacements.
Question 404: Hotchkiss terrible triad does not include which of the following injuries?
- A. Head of radius fracture
- B. Posterior elbow subluxation
- C. Olecranon fracture (Correct Answer)
- D. Fracture of coronoid process
Explanation: The **Terrible Triad of the Elbow**, first described by Hotchkiss, refers to a specific injury pattern characterized by severe elbow instability. It is termed "terrible" because it historically carried a poor prognosis with high rates of chronic instability and arthrosis. ### **Explanation of the Correct Answer** **C. Olecranon fracture:** This is the correct answer because it is **not** part of the classic triad. While olecranon fractures can occur alongside elbow trauma, they are typically associated with "Monteggia fracture-dislocations" or "Trans-olecranon fracture-dislocations," which have different injury mechanisms and management protocols than the Hotchkiss triad. ### **Analysis of Incorrect Options** The Hotchkiss Terrible Triad consists of the following three components: * **B. Posterior elbow dislocation/subluxation:** Usually results from a fall on an outstretched hand (FOOSH) with the elbow in semi-flexion, leading to a posterolateral rotatory instability pattern. * **A. Radial head fracture:** The radial head acts as the primary secondary stabilizer against valgus stress; its fracture compromises lateral stability. * **D. Fracture of the coronoid process:** The coronoid process is the "key" anterior stabilizer. Even a small (Regan-Morrey Type I) fracture significantly increases the risk of recurrent posterior dislocation. ### **High-Yield Clinical Pearls for NEET-PG** * **Mechanism:** Valgus stress + Axial loading + Supination (Posterolateral Rotatory Instability). * **Primary Goal of Surgery:** To restore enough stability to allow for **early range of motion** to prevent elbow stiffness (the most common complication). * **Classification:** Coronoid fractures are classified by **Regan-Morrey**, while radial head fractures use the **Mason Classification**. * **Management Priority:** 1. Fix/Replace Radial Head → 2. Repair Coronoid/Anterior Capsule → 3. Repair Lateral Collateral Ligament (LCL).
Question 405: What is the management of hemarthrosis?
- A. Compression bandage
- B. Needle aspiration
- C. Plaster of Paris cast
- D. All of the above (Correct Answer)
Explanation: **Explanation:** Hemarthrosis refers to bleeding into a joint cavity, most commonly occurring in the knee following trauma (e.g., ACL tear or patellar dislocation) or in patients with bleeding disorders like Hemophilia. The management strategy focuses on pain relief, pressure to control bleeding, and joint stabilization. **Why "All of the above" is correct:** The standard management of acute traumatic hemarthrosis follows a multimodal approach: 1. **Needle Aspiration (Arthrocentesis):** This is both diagnostic and therapeutic. Removing the blood under aseptic conditions provides immediate relief from intense pain caused by joint capsule distension and prevents the proteolytic enzymes in the blood from damaging the articular cartilage. 2. **Compression Bandage (Robert-Jones Bandage):** Applying a firm compression bandage helps limit further intra-articular bleeding and reduces inflammatory edema. 3. **Plaster of Paris (POP) Cast/Slab:** Immobilization is crucial to provide rest to the injured structures, prevent re-bleeding from movement, and alleviate muscle spasms. **Clinical Pearls for NEET-PG:** * **Rapid vs. Slow Swelling:** Swelling appearing within **0-2 hours** post-injury suggests **hemarthrosis** (vascular injury). Swelling appearing after **6-12 hours** suggests **traumatic effusion** (synovial fluid). * **Fat Globules:** If aspirated blood contains fat globules (lipohemarthrosis), it is pathognomonic for an **intra-articular fracture** (e.g., Tibial plateau fracture). * **Most Common Cause:** The most common cause of traumatic hemarthrosis in a stable joint is an **ACL tear**. * **Golden Rule:** Always rule out a fracture via X-ray before performing aspiration or applying a tight cast.
Question 406: Which nerve is commonly involved in a fracture of the distal shaft of the humerus?
- A. Radial nerve (Correct Answer)
- B. Median nerve
- C. Ulnar nerve
- D. Circumflex brachial nerve
Explanation: **Explanation:** The correct answer is **Radial nerve**. This is a classic high-yield anatomical relationship frequently tested in NEET-PG. **1. Why the Radial Nerve is Correct:** The radial nerve travels in the **spiral groove** (radial groove) located on the posterior aspect of the humerus. As it descends, it pierces the lateral intermuscular septum to enter the anterior compartment in the distal third of the arm. In fractures of the **distal third of the humeral shaft** (specifically **Holstein-Lewis fractures**), the nerve is prone to entrapment or laceration because it is relatively fixed against the bone at this site. **2. Why the Other Options are Incorrect:** * **Median Nerve:** This nerve travels medially and is more commonly injured in **supracondylar fractures** of the humerus (extension type), rather than shaft fractures. * **Ulnar Nerve:** The ulnar nerve is most vulnerable at the **medial epicondyle** (cubital tunnel). It is rarely involved in shaft fractures unless there is significant medial displacement. * **Circumflex Brachial (Axillary) Nerve:** This nerve winds around the **surgical neck** of the humerus. It is the most common nerve injured in proximal humerus fractures or anterior shoulder dislocations. **3. Clinical Pearls for NEET-PG:** * **Holstein-Lewis Fracture:** A spiral fracture of the distal 1/3rd of the humerus associated with radial nerve palsy. * **Clinical Sign:** Radial nerve injury leads to **Wrist Drop** (loss of wrist and finger extensors) and sensory loss over the first dorsal web space. * **Management:** Most radial nerve palsies in closed humeral fractures are **neuropraxias** and recover spontaneously (85-90% recovery rate). Immediate exploration is only indicated in open fractures or if the palsy develops *after* manipulation.
Question 407: What is the most important cause of nonunion of a humeral shaft fracture?
- A. Comminuted fracture
- B. Compound (Open) fracture
- C. Overriding of fracture ends
- D. Distraction at fracture site (Correct Answer)
Explanation: ### Explanation **Correct Answer: D. Distraction at fracture site** The humeral shaft is a common site for nonunion, and **distraction (separation) of the fracture fragments** is considered the most significant cause. In the humerus, distraction often occurs due to the **weight of the hanging cast** or excessive traction, which pulls the bone ends apart. This creates a gap that the callus cannot bridge, leading to a failure of the healing process. Unlike weight-bearing bones (like the femur), the humerus does not benefit from natural axial loading during early recovery, making it highly sensitive to over-distraction. **Analysis of Incorrect Options:** * **A. Comminuted fracture:** While comminution indicates a high-energy injury and can complicate healing, the increased surface area of the fragments often facilitates callus formation, provided the blood supply is intact. * **B. Compound (Open) fracture:** Open fractures increase the risk of infection (which can lead to nonunion), but with modern debridement and antibiotics, they are not the primary mechanical cause of nonunion compared to distraction. * **C. Overriding of fracture ends:** Overriding (shortening) actually increases the contact area between bone fragments and promotes healing through stable secondary ossification. It is a sign of "impaction," which is generally favorable for union. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of nonunion in the humerus:** Junction of the proximal and middle thirds. * **Holstein-Lewis Fracture:** A spiral fracture of the distal third of the humeral shaft associated with **Radial Nerve palsy**. * **Acceptable angulation:** The humerus is forgiving; up to 20° of anterior/posterior angulation and 30° of varus/valgus angulation are often acceptable for functional recovery. * **Treatment of choice:** Most humeral shaft fractures are managed conservatively with a **U-slab or Functional Bracing (Sarmiento Brace)**. Surgery (ORIF with Plate) is indicated for "floating elbow," vascular injury, or failed closed reduction.
Question 408: What is considered the golden hour for a femur fracture?
- A. 1 hour after injury (Correct Answer)
- B. 1 hour prior to injury
- C. 1 hour after reaching the hospital
- D. 1 hour after surgical procedure
Explanation: **Explanation:** The concept of the **"Golden Hour"** in trauma refers to the critical period immediately following a traumatic injury, such as a femur fracture, during which prompt medical intervention and stabilization significantly increase the chances of survival and reduce long-term morbidity. **1. Why Option A is Correct:** The "Golden Hour" begins at the **moment of injury**. In high-energy trauma like a femur fracture, the patient is at high risk for life-threatening complications, including **hypovolemic shock** (due to significant internal blood loss, often 1–1.5 liters) and **fat embolism syndrome**. Immediate resuscitation, immobilization (using a Thomas splint), and stabilization within this first hour are vital to prevent the "lethal triad" of acidosis, coagulopathy, and hypothermia. **2. Why the Other Options are Incorrect:** * **Option B:** This is logically impossible as medical intervention cannot occur before the injury happens. * **Option C:** Waiting until the patient reaches the hospital ignores the "Platinum Ten Minutes" of pre-hospital care. If transport is delayed, the golden hour may be exhausted before arrival. * **Option D:** This refers to the post-operative recovery phase, which is important for rehabilitation but does not define the emergency stabilization window. **High-Yield Clinical Pearls for NEET-PG:** * **Blood Loss:** A closed femoral shaft fracture can lead to **1000–1500 ml** of internal hemorrhage. * **Splintage:** The **Thomas Splint** is the gold standard for emergency immobilization to prevent further soft tissue damage and reduce fat embolism risk. * **Fat Embolism Syndrome (FES):** Classically presents with the triad of dyspnea, confusion, and petechial rashes (usually 24–72 hours post-injury). * **Management:** Early Total Care (ETC) vs. Damage Control Orthopaedics (DCO) depends on the patient's hemodynamic stability.
Question 409: All of the following areas are commonly involved sites in pelvic fracture except?
- A. Pubic rami
- B. Alae of ilium
- C. Acetabulum
- D. Ischial tuberosities (Correct Answer)
Explanation: **Explanation:** Pelvic fractures typically occur due to high-energy trauma (e.g., motor vehicle accidents) or low-energy falls in the elderly. The stability of the pelvic ring depends on its bony architecture and strong ligamentous complexes. **Why Ischial Tuberosities are the correct answer:** The **ischial tuberosities** are thick, robust bony prominences that serve as the primary weight-bearing site when sitting and the origin for the hamstring muscles. While they can be involved in isolated **avulsion fractures** (common in young athletes), they are **not** considered a common site for major pelvic ring disruptions or fractures compared to the other options. **Analysis of Incorrect Options:** * **Pubic Rami:** These are the **most common** sites of pelvic fractures. Because the pelvis is a rigid ring, a break in one part often leads to a break elsewhere; the thin pubic rami frequently give way under compressive forces. * **Alae of Ilium:** The iliac wings are broad, relatively thin plates of bone susceptible to direct trauma (e.g., "Duverney’s fracture"). They are frequently involved in lateral compression injuries. * **Acetabulum:** This is a common site of fracture, often occurring when the head of the femur is driven into the pelvis (e.g., dashboard injuries). It is clinically significant as it involves the articular surface of the hip joint. **NEET-PG High-Yield Pearls:** * **Most common site of pelvic fracture:** Superior and inferior pubic rami. * **Stable vs. Unstable:** Fractures involving only one part of the ring (e.g., isolated ramus fracture) are stable; disruptions in two or more places (e.g., Malgaigne fracture) are unstable. * **Associated Injury:** The most common life-threatening complication of pelvic fractures is **hemorrhage** (usually from the posterior venous plexus). * **Urethral Injury:** High suspicion is required in males with pubic symphysis diastasis or rami fractures (look for "high-riding prostate").
Question 410: Which tendon is affected in lateral epicondylitis?
- A. Extensor Carpi Radialis Brevis (Correct Answer)
- B. Extensor Carpi Radialis Longus
- C. Flexor Pollicis Longus
- D. Supinator
Explanation: **Explanation:** **Lateral Epicondylitis**, commonly known as **Tennis Elbow**, is a clinical condition characterized by pain and tenderness over the lateral epicondyle of the humerus. It is caused by repetitive microtrauma and overuse, leading to angiofibroblastic hyperplasia (degenerative changes) rather than true inflammation. 1. **Why Option A is Correct:** The **Extensor Carpi Radialis Brevis (ECRB)** is the most commonly involved tendon. It originates from the lateral epicondyle. Because of its anatomical position, the underside of the ECRB tendon rubs against the lateral capitellum during elbow extension and forearm pronation, making it highly susceptible to wear, tear, and microscopic failure. 2. **Why Other Options are Incorrect:** * **Extensor Carpi Radialis Longus (ECRL):** While it originates near the lateral epicondyle (supracondylar ridge), it is rarely the primary site of pathology in tennis elbow. * **Flexor Pollicis Longus:** This is a deep muscle of the anterior (flexor) compartment of the forearm. It is unrelated to lateral epicondylar pathology. * **Supinator:** Although the supinator lies deep in the lateral elbow, it is not the primary tendon involved. However, the **posterior interosseous nerve** passes through the supinator (Arcade of Frohse), which is a differential diagnosis for lateral elbow pain (Radial Tunnel Syndrome). **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Test:** **Cozen’s Test** (pain on resisted wrist extension with elbow extended) and **Mill’s Test** (pain on passive wrist flexion with elbow extended). * **Medial Epicondylitis (Golfer’s Elbow):** Involves the common flexor origin, most commonly the **Pronator Teres** and **Flexor Carpi Radialis (FCR)**. * **Treatment:** Primarily conservative (NSAIDs, eccentric exercises, bracing). Surgery (Nirschl debrisment) is reserved for refractory cases.
Practice by Chapter
Principles of Fracture Management
Practice Questions
Upper Limb Fractures
Practice Questions
Lower Limb Fractures
Practice Questions
Spinal Trauma
Practice Questions
Pelvic and Acetabular Fractures
Practice Questions
Open Fractures
Practice Questions
Fractures in Children
Practice Questions
Fracture Complications
Practice Questions
Nonunion and Malunion
Practice Questions
Polytrauma Management
Practice Questions
Joint Dislocations
Practice Questions
Soft Tissue Injuries
Practice Questions
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